RU2746653C1 - Method for extraction of cataracts complicated by pseudoexfoliation syndrome - Google Patents

Abstract

FIELD: medicine; ophthalmology.

SUBSTANCE: tunnel incision and two paracenteses are formed; a mydriatic and a viscoelastic are inserted into the anterior chamber. Anterior capsulorhexis, hydrodissection of the lens nucleus, phacoemulsification of the lens nucleus are performed by ultrasound. An intraocular lens is implanted into the capsular bag. Next, the intracapsular ring, the primary posterior capsulorhexis are implanted, followed by the washing out of the viscoelastic from the capsular bag and the anterior chamber and pseudoexfoliation deposits from the angle of the anterior chamber. Hydrodissection is performed without rotation of the lens nucleus. Phacoemulsification of the lens is carried out by a non-rotational method with a gentle hydrodynamic regime: intraocular pressure (IOP) – 30-40 mm Hg, vacuum – 200-400 mm Hg, aspiration flow rate – 20-23 mm/min. Continuous linear torsion ultrasound mode with 50% amplitude and IP technology is applied. After the completion of the ultrasound stage, the intraocular lens (IOL) of the step-arched design is implanted through the injector, and the primary posterior capsulorhexis is performed after the implantation of the intraocular lens.

EFFECT: method allows increasing efficiency and safety of the operation, as well as reducing the risk of developing secondary cataracts and contraction capsular syndrome.

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Description

The invention relates to medicine, namely to ophthalmology, and can be used for phacoemulsification of complicated cataracts.

The successful development of phacoemulsification technologies made it possible to significantly expand the indications for this operation and make it effective and safe even in difficult cases, which include pseudoexfoliative syndrome (PES).

Pseudoexfoliative syndrome is characterized by the deposition of a pseudoexfoliative substance on all structures of the anterior part of the eyeball, dystrophic changes in the iris and ciliary body; thinning and decreasing elasticity of the lens capsule; a decrease in the strength of the zinc bond and phacodonese; increased pigmentation of the anterior chamber angle; violation of the hydrodynamics of the eye; in cases of cataract development - high density of the nucleus and cortical layers, the risk of postoperative decompensation of intraocular pressure and the development of such long-term complications as secondary cataract, contraction capsular syndrome (CCS) and late dislocation of the "capsular bag - IOL" complex.

A known method for the extraction of solid cataracts, including the formation of a tunnel incision and paracentesis, the introduction into the anterior chamber of mydriatic and viscoelastic, capsulorhexis, hydrodissection of the lens nucleus, cataract extraction by ultrasonic phacoemulsification, while initially forming a coloboma of the nucleus using an ultrasonic tip at least half the diameter of the nucleus , then the remaining part of the core is removed mechanically by means of a hook by rotating the remaining part of the core to the site of the tunnel cut, followed by removal of this part from the cut by rotation (Patent RU 2245122, op. 27.01.2005).

However, this method is not effective in the presence of pseudoexfoliative syndrome and has sufficient trauma during the extraction of solid cataracts, and also does not exclude the possibility of secondary cataract occurrence in the long-term period.

A known method of cataract extraction in patients with pseudoexfoliative syndrome, including the formation of a tunnel incision and paracentesis, the introduction of mydriatic and viscoelastic into the anterior chamber, capsulorhexis, hydrodissection of the lens nucleus, cataract extraction by the method of ultrasonic phacoemulsification in a pulsed mode "flash", implantation of the ring inside the ring subsequent washing out of the viscoelastic from the capsule bag and the anterior chamber and washing out pseudoexfoliative deposits from the corner of the anterior chamber (patent RU 2313320 C1, publ. 27.12.2997).

The disadvantages of this method are its relative trauma in pseudoexfoliation syndrome and the possibility of secondary cataract in the long-term postoperative period.

The closest to the claimed method - the prototype, is a method of cataract extraction in patients with pseudoexfoliative syndrome, including the formation of a tunnel incision and paracentesis, the introduction of mydriatic and viscoelastic into the anterior chamber, capsulorhexis, hydrodissection of the lens nucleus, cataract extraction by ultrasonic phacoemulsification of the lens nucleus carried out in the form of the Latin letter Y, after which the wedge-shaped fragment of the lens nucleus is removed for 6 hours, then the adjacent fragments of the lens are sequentially fragmented and removed, then the intraocular lens is implanted through the injector into the capsule bag, followed by washing out the viscoelastic from the capsule bag and the anterior chamber and pseudoexfoliative deposits from the corner of the anterior chamber, while before or after implantation of the IOL, primary posterior capsulorhexis is performed (Patent RU 2504353 C1, publ. 20.01.14).

The disadvantages of this method are the difficulty of manipulation with induced intraoperative miosis and the possibility of developing contraction capsular syndrome.

The objective of the invention is to develop a safer and more sparing method for the extraction of cataracts complicated by RPE, which makes it possible to reduce the load on the ligamentous-capsular apparatus of the lens, to avoid the occurrence of secondary cataracts and contraction capsular syndrome.

Technical result:

efficiency gains and

safety of the operation, as well as reducing the risk of developing secondary cataracts and contraction capsular syndrome.

The task is achieved by the proposed method, which is as follows.

Preoperative preparation begins 1 day before the operation by double installation of mydriatics (Midrimax), a non-steroidal anti-inflammatory drug (Indocollir 0.1%, Diclof) and an antibiotic or antiseptic (Signicef, Okomistin 0.01%).

The operation is performed with a limbal tunnel 2.2 mm wide at 10.30 o'clock and two paracenteses 1.2 mm wide at 3 and 9 o'clock. A combined viscoelastic is introduced into the anterior chamber, and in case of insufficient mydriasis, phenylephrine is administered. After anterior circular capsulotomy and hydrodissection at: IOP - 30-40 mm Hg, vacuum - 200-400 mm Hg, aspiration flow rate - 20-23 mm / min, continuous linear mode of torsion ultrasound with an amplitude of 50% and IP technology, excluding the stage of rotation of the lens nucleus, an ultrasonic phaco tip is introduced into the anterior chamber through the limbal tunnel, and through paracentesis at 3 o'clock the phacopper is formed in the lens nucleus (paracentrally in its left half), a deep oblique groove, asymmetrically displaced to the left , followed by a bimanual split along its entire length. Then, in a larger fragment of the nucleus using the vertical chop method, an oblique split is performed with a maximum shift of the fragmentation line to the right. Thus, a large "central wedge" is isolated and mobilized, capturing the central part of the nucleus. Subsequent removal of the isolated fragment is carried out in the space of the capsule bag without rotation and aggressive manipulations using the phacocop method. The two remaining peripheral segments of the nucleus in the empty capsular sac of the lens are easily moved by the chopper without rotation and compression onto the ligamentous-capsular apparatus of the lens into the pupillary zone for their further phacoemulsification. FIG. 1 shows a diagram of the non-rotation removal of the lens nucleus.

To facilitate the implementation of the stage of removing the nucleus of the lens against the background of RPE, a phacopper with a pusher on the back of the instrument is mainly used for retraction of the iris edge and safe separation of the lens nucleus in case of insufficient intraoperative mydriasis.

After removal of the lens nucleus and cortical masses, the intracapsular ring is implanted to evenly distribute the load on the ligamentous apparatus of the lens and prevent its further degradation. With significantly pronounced zonular incompetence during the operation, iridocapsular retractors are additionally used.

To prevent opacification of the anterior capsule when replacing a clouded lens, an intraocular lens (IOL) of a stepped-arched design (Tecnis, Abbott; enVista, B&L) is implanted with a protruding edge of the optical part of the IOL, which prevents the anterior capsule from contacting the lens body.

During the operation, regardless of the degree of transparency of the posterior capsule, always perform primary posterior capsulorhexis (PPCR) after IOL implantation. For this, the capsule bag is partially filled with viscoelastic, and a microperforation is formed in the central part of the posterior capsule with a 30G disposable injection needle. A small amount of viscoelastic is injected into the perforation zone of the posterior capsule to prevent entrapment of the anterior hyaloid membrane. Coaxial forceps 25 G form a circular posterior capsulorhexis with a diameter of 3.0-4.5 mm. Then, the viscoelastic is evacuated from the capsular bag and the anterior chamber and pseudoexfoliative deposits from the corner of the anterior chamber.

The proposed method allows at the beginning of the ultrasound stage to mobilize in the form of a "central wedge" most of the nucleus and then safely remove it under visual control without rotation and additional tension of the zinn ligament. The top of the "wedge" is the central densest part of the nucleus, often "holding" its entire "structure" throughout most of the ultrasonic stage. The primary removal of the central part of the nucleus instantly changes its entire architectonics, increasing the mobility of the remaining fragments. Localization of irrigation and aspiration work in the capsular bag not only allows one to distance ourselves from the endothelium, but also stimulates hydrodynamics in the capsular bag of the lens, increasing the mobility of lens fragments. The remaining two peripheral segments of the nucleus move without excessive effort into the pupillary zone and are removed under visual control.

The defining essential differences of the proposed method, in comparison with the prototype, are:

- removal of the lens is carried out in a gentle ultrasonic and hydrodynamic mode: IOP - 30-40 mm Hg. Art., vacuum - 200-400 mm Hg. Art., aspiration flow rate - 20-23 mm / min, continuous linear mode of torsion ultrasound with an amplitude of 50% and IP-technology, excluding the stage of rotation of the lens nucleus, which makes it possible to reduce intraoperative zonular stress;

- after the completion of the ultrasound stage, the intracapsular ring is implanted through the injector and the primary posterior capsulorhexis is performed, taking into account the peculiarities of the pseudoexfoliative syndrome, which makes it possible to reduce the likelihood of secondary cataract development, as well as long-term undesirable consequences associated with progressive instability of the ligamentous apparatus.

implantation of an intraocular lens of a stepped-arched design, excluding the contact of the PCH-IOL, which makes it possible to reduce the likelihood of developing opacity and contraction capsular syndrome.

As you know, the contact of the PCC-IOL is a stimulus for the process of epithelial-mesenchymal transition with fibroplasia of the anterior subcapsular epithelium. OCT control showed that with intracapsular IOL implantation of a stepped-vaulted design, there is no adhesion of the anterior capsule to the surface of the optical part of the IOL, the anterior subcapsular epithelium remains unchanged and does not realize its potential for fibroplastic transformation.

Peculiarities (modification) of carrying out PZKR against the background of PES are as follows:

1. Before performing the posterior capsulorhexis, the intracapsular ring is implanted, which allows to eliminate the imbalance in the tension of the Zinn ligament fibers and to straighten the posterior capsule, promoting its uniform axisymmetric tension, which allows better control of the direction of the posterior capsule flap separation and excludes its "escape" to the periphery.

2. Partial filling of the capsular bag with viscoelastic is carried out in a volume sufficient only to expand the posterior capsule, since excessive filling of the capsular bag with viscoelastic increases the tension of the posterior leaf and reduces control during the formation of the posterior lens capsule flap (PCL).

3. Viscoelastic is injected under the posterior capsule in a minimal amount only in the area of its perforation to exclude the capture of the anterior hyaloid membrane, and therefore the stage of removing the viscoelastic from the posterior capsulorhexis area associated with the risk of vitreous prolapse is excluded.

The invention is illustrated by the following specific examples.

Example 1.

Patient N., 78 years old, was admitted to the Novosibirsk branch of the MNTK "Eye Microsurgery" with a diagnosis of complicated incomplete cataract in both eyes, pseudoexfoliative syndrome stage II (according to the classification of A.P. Nesterov, 2008).

Visual acuity of the right eye - 0.05 k / n; visual acuity of the left eye - 0.5 k / n.

The patient underwent cataract phacoemulsification with IOL implantation by the claimed method on the right eye.

One day before the operation, a double installation of Midrimax, 0.1% Indocollir solution and 0.01% Okomistin was performed.

After performing a limbal tunnel with a width of 2.2 mm and two paracenteses with a width of 1.2 mm at 9 and 3 o'clock, a combined viscoelastic (Diskovisk, Alcon) was introduced into the anterior chamber. Then, a sparing hydrodissection was performed without rotation of the lens nucleus. Through the limbal tunnel, the tip of the phacoemulsifier was introduced into the anterior chamber, and through the paracentesis at 3 o'clock - a chopper with a pusher for the pupillary edge on its back. The lens was removed in a gentle hydrodynamic mode. To remove the lens, we used a Centurion Vision System phakomachine with Active Fluidics technology and a combination of settings aimed at reducing the hydrodynamic and ultrasonic intraoperative load on the structures of the anterior segment of the eye. The following working settings of the facomachine were used: IOP - 32 mm Hg, vacuum - 400 mm Hg, aspiration flow rate - 20 mm / min, continuous linear mode of torsion ultrasound with an amplitude of 50% and IP technology.

Through the injector, the intracapsular ring was implanted, which is an open ring, at the free ends of which there are bows facing inwardly with holes at their ends.

The primary posterior capsulorhexis was performed after complete evacuation of the lens masses. For this, the capsule bag was partially filled with viscoelastic, and a microperforation was formed in the central part of the posterior capsule with a 30G disposable injection needle. A small amount of viscoelastic was injected into the perforated area of the posterior capsule. Coaxial forceps 25 G formed a circular posterior capsulorhexis with a diameter of 3.5 mm. A stepped-arch design IOL (Tecnis, Abbott) was implanted into the capsule bag, after which the viscoelastic was evacuated from the capsule bag and the anterior chamber and pseudoexfoliative deposits from the corner of the anterior chamber.

The visual acuity of the right eye on the next day after the operation was 0.7 without correction. One month after surgery, visual acuity 0.8 sph-0.5 = 0.95

Example 2.

Patient M., 71 years old, was admitted to the Novosibirsk branch of the IRTC "Eye Microsurgery" with a diagnosis of complicated incomplete cataract in both eyes, pseudoexfoliative syndrome stage II (according to the classification of A.P. Nesterov, 2008).

Visual acuity of the right eye - 0.2 k / i; visual acuity of the left eye -0.5 cyl + 0.75 ax15 ° = 0.6.

The patient underwent an operation - phacoemulsification of a cataract with IOL implantation by the claimed method on the right eye.

One day before the operation, a two-time installation of Midrimax, Diklo-f and Signicef was carried out.

After performing a limbal tunnel 2.2 mm wide and two paracenteses at 9 and 3 o'clock, a combined viscoelastic (Diskovisk, Alcon) was introduced into the anterior chamber, hydrodissection was performed without rotation of the lens nucleus.

Through the limbal tunnel, the tip of the phacoemulsifier was introduced into the anterior chamber, and through the paracentesis at 3 o'clock - a chopper with a pusher for the pupillary edge on its back. The lens was removed in a gentle hydrodynamic mode: IOP - 35 mm Hg. Art., vacuum - 400 mm Hg. Art., aspiration flow rate - 23 mm / min, continuous linear mode of torsion ultrasound with an amplitude of 50% and IP technology.

The intracapsular ring was implanted through the injector.

Primary posterior capsulorhexis was performed after implantation of a stepped-vaulted IOL (enVista, Bausch & Lomb) similarly to example 1. The viscoelastic was washed out from the capsular sac and anterior chamber and pseudoexfoliative deposits from the anterior chamber angle.

The visual acuity of the right eye on the next day after the operation was 0.8 without correction. One month after the operation, the visual acuity was 0.9 without correction.

2.5 years after the operation, the visual acuity was uncorrected, no opacities and contractures of the anterior lens capsule were observed. FIG. 2 shows biomicroscopy of the right eye, which shows a transparent anterior capsule along the edge of the anterior capsulorhexis. FIG. 3 shows the OCT scan, which shows the absence of contact of the anterior capsule with the optical part of the IOL and the unchanged hyperreflective layer of the A-epithelium.

The method makes it possible to increase the efficiency and safety of cataract surgery in cases complicated by pseudoexfoliative syndrome by solving the following problems:

- reduction of mechanical trauma to the zonular apparatus and the lens capsule by excluding rotation of the lens nucleus at all stages of the operation;

- reduction of hydrodynamic trauma and ultrasound effects on the structures of the eye as a result of the use of optimal phacodynamic modes with reduced irrigation;

- improving the visualization of the main stages of the operation due to the use of a phacopper with a pusher for retraction of the pupillary edge;

- prevention of clouding and contracture of the anterior lens capsule by implanting an IOL with a stepped-arched design, which excludes the contact of the anterior capsule with the IOL surface.

The use of the proposed method will reduce the risk of secondary cataract formation, contraction capsular syndrome, reduce the load on the ligamentous-capsular apparatus of the lens and avoid serious intraoperative complications

Claims (1)

A method of cataract extraction complicated by pseudoexfoliative syndrome, including the formation of a tunnel incision and two paracentesis, introduction of mydriatic and viscoelastic into the anterior chamber, anterior capsulorhexis, hydrodissection of the lens nucleus, phacoemulsification of the lens nucleus using ultrasound, implantation into the intraocular lens ring posterior capsulorhexis followed by washing out of the viscoelastic from the capsular bag and anterior chamber and pseudoexfoliative deposits from the angle of the anterior chamber, characterized in that hydrodissection is performed without rotation of the lens nucleus, phacoemulsification of the lens is carried out by a non-rotational method with a sparing hydrodynamic mode: IOP -30-40 ., vacuum - 200-400 mm Hg, aspiration flow rate - 20-23 mm / min, continuous linear mode of torsion ultrasound with an amplitude of 50% and IP technology, after the completion of the ultrasound stage, through the injector, implantation is performed a stepped-vaulted IOL design, and primary posterior capsulorhexis is performed after intraocular lens implantation.

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